GENERAL PRACTICE

The Clinical Survival Guide

Contents
Foreword ix
Acknowledgements x
Glossary xi
1 Cardiovascular disease 3
Hypertension 1
Anti-platelet therapy 4
Angina management 12
Peripheral artery disease (PAD) 19
CVA management: National Clinical Guidelines for Stroke
(June 2004) 20
Heart failure 23
Atrial fibrillation 26
2 Dementia 27
Dementia 29
Mini-mental state examination 33
3 Driver and Vehicle Licensing Agency (DVLA) regulations 35
Common medical conditions affecting eligibility to drive
(Group 1 regulations, ie to drive private vehicle) 38
Fitness to fly` 41
4 Endocrinology 43
Diabetes mellitus 45
Thyroid disease 54
Hypothyroidism 55
Hyperthyroidism 58
Hypnotraemia 59
5 ENT 61
Introduction 63
Ears 64
Nose 69
Throat 71
Vertigo 73
6 Gastroenterology 77
Irritable bowel syndrome 79
Food Allergies 83
Coeliac disease 85
Inflammatory bowel disease 87
Dyspepsia 90
Gastro-oesophageal reflux disease (GORD) 92
Hepatitis C 96
Hepatitis B 99
Abnormal LFTs 100
Low B12 and folate 105
7 Gynaecology 107
The menstrual cycle 109
Intermenstrual bleeding 110
Polycystic ovarian syndrome (PCOS) 113
Hirsutism 116
Endometriosis 117
Cervical smears 118
Contraception 119
Termination of pregnancy 127
Premenstrual syndrome 128
The menopause 129
Incontinence 136
Pruritus vulvae and vulvovaginitis 139
8 Haematology 141
Abnormal blood results 143
Other haematological conditions 147
9 Neurology 149
Headaches 151
Epilepsy 156
Parkinsons disease 159
10 Obstetrics 161
Antenatal and postnatal care 163
VI
11 Ophthalmology 171
Blepharitis 173
Excess lacrimation 174
Dacryocystitis (lacrimal sac infection) 175
Chalazion 176
Stye 177
Pterygium 178
Bacterial conjunctivitis 179
Allergic conjunctivitis 180
Macular degeneration 181
Blindness 182
12 Orthopaedics 183
Fracture care 185
Twisted ankles 193
The acutely painful knee 194
Frequently missed diagnoses 197
Back pain 201
Orthopaedic malignancy 202
Osteoarthritis 203
Normal conditions misdiagnosed as abnormal 207
13 Paediatrics 211
Feeding 213
Weaning 218
Teething 219
Small fontanelle 220
Sticky eyes 221
Rashes 222
Undescended testicles 224
Circumcision 225
Behavioural problems 226
Food intolerance 228
Nocturnal enuresis 229
Common viral rashes in childhood 231
Childhood migraine 233
VII
CHAPTER 1
CARDIOVASCULAR DISEASE
CHAPTER 1
CARDIOVASCULAR DISEASE
For this chapter, it is worth noting that coronary heart disease (CHD) refers to
myocardial infarction (MI), angina and coronary artery disease (eg patients
who have had bypass operations or angioplasties).
The term cardiovascular disease (CVD) incorporates cerebrovascular disease
and peripheral vascular disease, as well as CHD. The CVD risk can be
calculated by multiplying the CHD risk by 4/3: for example, a CHD risk of
15% is equivalent to a CVD risk of 20%. CVD risk is a more important
measurement than CHD risk in many ways and has been used in the latest
Joint British Society risk charts.
Treatment guidelines are becoming ever more stringent, with drugs for
primary prevention being started earlier and earlier; there seems to be a
danger that if this trend continues, most of the older UK population will end
up on medication to prevent CVD. However, it should never be forgotten that
most CVD can be prevented by modifying lifestyle factors: for example,
smoking 610 cigarettes a day doubles the risk of MI, while smoking 20
cigarettes increases the risk fourfold and smoking 40 cigarettes leads to a
ninefold increase in risk.
3
HYPERTENSION
The British Hypertension Society (BHS) updated their guidance in 2004,
based on evidence from several large-scale studies. These guidelines have
proved to be quite controversial and many GPs feel that the targets are
unrealistic and too complicated, especially in their cholesterol
recommendations. A more pragmatic approach is to reduce blood pressure to
the lowest level that the patient can tolerate.
The BHS classification of hypertension is summarised in Table 1.1:
Blood pressure (mmHg)
Systolic Diastolic
Optimal BP <120 <80
Normal BP <130 <85
High normal BP 130139 8589
Grade 1 hypertension 140159 9099
Grade 2 hypertension 160179 100109
Grade 3 hypertension >180 >110
Isolated systolic hypertension (grade 1) 140159 <90
Isolated systolic hypertension (grade 2) >160 <90
Table 1.1: BHS classification of hypertension (with copyright permission from
the British Hypertension Society, BHS classification of blood pressure levels,
Journal of Human Hypertension, 2004, 18, p.142, Box 1)
In the USA, patients with highnormal BPs are labelled as having pre-
hypertension. Fortunately, given the huge number of people who would fall
into this disease category, the term is not yet being used in the UK!
MONITORING BP (ACCORDING TO THE BHS)
All adults should routinely have their BP monitored every 5 years.
Adults with highnormal BPs and those who have had high readings
at any time in the past should have their BP measured annually (if
implemented, this would mean a hugely increased workload for GPs,
particularly in terms of monitoring patients with highnormal BPs).
4 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
An appropriate size of cuff should be used, such that the bladder
covers at least 80% of the upper arm. Using a cuff that is too small
will lead to an overestimation of BP and vice versa. There are three
sizes of cuff available.
The BP should be measured with the arm supported at heart level.
NOTE: Elderly patients often have a postural drop in BP. Therefore, in these
patients, BP should also be measured when they are standing (after at least
2 minutes standing). If there is a postural drop of >20 mmHg, use the
standing BP.
ESTABLISHING THE DIAGNOSIS
BP is very variable, particularly in the elderly. It is therefore recommended to
measure BP on a minimum of three different occasions (but ideally more)
before initiating therapy. Treatment may be needed if either the systolic BP or
the diastolic BP is raised.
For grade 1 hypertensives (BP 140159/9099 mmHg) without
diabetes, target organ damage (eg left ventricular hypertrophy (LVH)
or renal impairment) or cardiovascular disease (CVD), confirm the
diagnosis by taking two measurements per visit, repeated monthly
over 46 months. Decide on whether to treat according to CVD risk
(treat if >20% over 10 years).
For grade 1 hypertensives with diabetes, target organ damage or
CVD, confirm the diagnosis of hypertension over the course of
3 months, and then treat.
For grade 2 hypertensives (BP 160179/100109 mmHg), confirm
the diagnosis over 13 months and start treatment. For grade 2
hypertensive patients with complications, confirm over 34 weeks,
and then treat; everybody with a BP of >160/100 mmHg needs
treatment.
For grade 3 hypertensives (BP >180/110 mmHg), confirm over 12
weeks, and then treat. Immediate treatment is needed if the BP is
>220/120 mmHg; this should be according to normal treatment
guidelines (see below). Admission is required for patients with
malignant hypertension, ie if the patient is showing signs of
encephalopathy (headache, focal central nervous system (CNS) signs,
papilloedema, drowsiness, blurred vision).
5 CARDIOVASCULAR DISEASE
INITIAL MANAGEMENT
When a diagnosis has been established, all hypertensive patients should have
the following investigations:
Urea and electrolytes (U&Es)
Fasting lipid profile
Fasting glucose
Urine dipstick analysis for protein and blood (to exclude renal disease)
ECG (echo is indicated if there are ECG signs of left ventricular
hypertrophy).
Stop any medication that might make the BP worse, eg anti-inflammatories,
steroids and the oral contraceptive pill. Lifestyle interventions are vital for
everybody: exercise, smoking cessation, weight loss and a low-salt diet.
TREATMENT TARGETS
For most patients over the age of 50, systolic BP is more important than
diastolic BP in terms of risk of CVD.
In non-diabetic patients, the aim is to reduce the BP to below
140/85 mmHg. The maximum acceptable level (audit standard) is
150/90 mmHg.
In diabetic patients, patients with established CVD and patients
with renal impairment, BP should be reduced to below 130/80
mmHg. The maximum acceptable level is 140/80 mmHg.
NOTE: These values are based on clinic readings. Targets for ambulatory BP
readings and home readings should be adjusted downwards by 10/5 mmHg.
Therefore, compared to the clinic target of 140/85 mmHg, average home
readings and ambulatory BP readings should be <130/80 mmHg (with
average night-time BP <120/70 mmHg and average daytime BP <135/85
mmHg for ambulatory readings).
WHAT MEDICATION TO USE?
This is where it gets confusing! The National Institute for Clinical Excellence
(NICE) and the BHS offer different guidance on initial treatment. NICE
suggests the initial use of a thiazide diuretic for all patients over the age of 55
(except those with gout, unless covered with allopurinol); this is based mainly
on the large ALLHAT study, which was carried out in the USA (Journal of the
American Medical Association 2002; 288: 29812997). However, critics of
6 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
the ALLHAT study claim that it cannot be applied to the UK population,
because a large percentage of trial patients (35%) were Afro-Caribbean, and
this group responds particularly well to diuretics.
7 CARDIOVASCULAR DISEASE
*Patients at high risk of diabetes:
Strong family history of diabetes
Impaired glucose tolerance
Fasting glucose >6.5 mmol/l
Clinically obese with body mass index (BMI) >30 kg/m
2
South Asians and Afro-Caribbeans.
Figure 1.1 NICE guidance (recommended by most Primary Care
Organisations). ACE, angiotensin-converting enzyme.
Start with a thiazide, or if not tolerated, a beta-
blocker. For patients under 55, consider start-
ing treatment with a beta-blocker.
BP not controlled
Add a beta-blocker unless high risk of dia-
betes.* If so, add an ACE inhibitor instead (or
angiotensin-receptor blocker if not tolerated)
BP not controlled
Add in a dihydropyridine calcium-
channel blocker
BP not controlled
Add other therapy as appropriate, eg
alpha-blocker
8 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
Patient <55 years and non-Black Patient >55 years or Black
BP not controlled BP not controlled
Combine A (or B) with C or D
BP not controlled
Combine A (or B) with C and D
BP not controlled
Add an alpha-blocker,
spironolactone or other diuretic
Start treatment with a calcium-channel
blocker or a thiazide diuretic
Start treatment with an ACE inhibitor or
angiotensin-receptor blocker (or
beta-blocker as second choice)
NOTE:
1 There is strong evidence to support the BHS guidelines when
treating Black patients; in most studies, beta-blockers and
angiotensin-converting enzyme (ACE) inhibitors have been shown to
be of no benefit in treating this group (Annals of Internal Medicine
2004; 141: 614627; Effective Health Care 2004; 8(4)).
2 The full benefit to be gained from any BP-lowering medication will
take about 4 weeks to achieve. If after 4 weeks BP control is still
suboptimal, the dose of the medication should be titrated up
(except for thiazides, which are not more effective at higher doses,
but may cause more side-effects). After this, it is reasonable either
to change to an alternative treatment (if the hypertension is mild),
or to add in a new drug.
Figure 1.2 BHS guidance: ABCD (with copyright permission from the British
Hypertension Society, Recommendations for combining blood pressure lowering
drugs/ABCD rule, Journal of Human Hypertension, 2004, 18, p.150, figure 3)
3 Long-term beta-blockers are still recommended for all patients with
CHD; there is evidence that they reduce mortality and morbidity in
patients with angina and after MI. Mortality is probably reduced by
2025% in post-MI patients given long-term beta-blockade (British
Medical Journal 1999; 318: 17301737). All patients who have had
an MI in the past should also be on long-term ACE inhibitors.
4 All diabetics with microalbuminuria should be on an ACE inhibitor
or angiotensin-receptor blockers (ARBs).
5 The role of beta-blockers in treating hypertension is currently being
questioned, following the findings of the ASCOT study (due to be
published in the Lancet in September 2005). This shows that using
an ACE inhibitor plus a calcium channel blocker cuts all cause
mortality by 15% compared to treatment with a beta-blocker and
thiazide diuretic. A systematic review on the efficiacy of atenolol
(Lancet 2004; 364: 16849) concluded that although atenolol
lowers BP, it has no effect on all cause mortality, cardiovascular
mortality or MI compared to placebo.
The rationale behind the BHS guidelines is that hypertension can be divided
into two categories: high renin and low renin hypertension. Younger, non-
Black patients are more likely to have high renin hypertension; studies have
shown that renin levels are higher in young people and in white people. ACE
inhibitors and beta-blockers both inhibit the reninangiotensin system, and
should therefore be more effective in these patient groups. NICE does not
support the BHS because there have been no large randomised controlled
trials yet to validate this approach, and thiazide diuretics are much cheaper
than other antihypertensive drug groups. The cost issue is a debatable one
however, in that it is likely that a higher percentage of patients will achieve
optimal BP control with only one agent if the BHS advice is followed,
compared with NICE guidance.
CAUTIONS
Dont use a thiazide diuretic in patients who suffer from gout, as it
may precipitate an attack.
ACE inhibitors and ARBs should not usually be used in patients with
moderate to severe aortic stenosis (if the gradient is >64 mmHg).
These drugs can exacerbate symptoms, but usually do so quickly if
they are going to have an adverse effect at all; cardiologists will
sometimes introduce them cautiously if there is concomitant left
ventricular dysfunction.
9 CARDIOVASCULAR DISEASE
ACE inhibitors can worsen renal function in patients with renal artery
stenosis.
Dont use beta-blockers in asthmatics, and use them with caution in
patients with peripheral artery disease and chronic obstructive
pulmonary disease (COPD). Patients whose COPD shows little or no
reversibility with beta-agonists (eg those with emphysema) will
probably be able to tolerate beta-blockers; in this case, a very low
dose of a cardioselective drug should be used.
Cardioselective beta-blockers (eg carvedilol and bisoprolol) are
preferable for patients with heart failure, but should be introduced
very gradually, probably under specialist supervision.
Adding a thiazide to a beta-blocker in patients at high risk of
developing diabetes is not recommended by the BHS or by NICE; the
LIFE trial (Lancet 2002; 359: 995) demonstrated a 15% excess risk of
new-onset type 2 diabetes over 5 years with this combination
compared with an ARB used with a thiazide diuretic. Indapamide
has a more favourable effect on glucose than bendroflumethiazide,
but is several times more expensive. Patients receiving beta-blockers,
even when used alone, are more likely to develop diabetes than
patients on ACE inhibitors or ARBs.
Extreme caution should be used if combining verapamil or diltiazem
with a beta-blocker, because the patient might be tipped into heart
failure. Long-acting dihydropyridine calcium-channel blockers (eg
amlodipine and felodipine) should be safe in combination with a
beta-blocker, but are more likely to cause ankle swelling than
diltiazem or verapamil. Short-acting calcium-channel blockers should
also be used with caution when combined with a beta-blocker.
MEASURING U&ES IN PATIENTS ON ACE INHIBITORS
Patients who have a normal baseline creatinine and who do not have
significant co-morbidities are at low risk of suffering from renal impairment
while on an ACE inhibitor. In these patients, the following measurements
should be made:
Baseline U&Es
A single U&E check while the dose is being titrated up
An annual U&E check.
This only applies to patients with normal renal function, which does not
deteriorate after the initial introduction of an ACE inhibitor; others will need
10 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
to be monitored more closely. ACE inhibitors should be withdrawn if the
creatinine rises by >50% of its baseline value, or exceeds 200 mol/l;
whichever is less.
HYPERTENSION IN THE ELDERLY
About 70% of people over the age of 60 in the UK have a BP of >140/90
mmHg. Elderly people are likely to benefit from blood pressure lowering as
much as, if not more than, younger patients in terms of lowering their
cerebrovascular accident (CVA) risk. Treatment can certainly be continued
beyond the age of 80 for anyone at significant risk of CVD, particularly if
they are otherwise well and do not suffer from adverse effects because of the
medication. However, it should be remembered that there is little trial
evidence supporting the use of antihypertensive treatment in the over-85 age
group, and the risk of falls from postural hypotension should not be
underestimated; mortality after a fractured neck of femur is very high.
Thiazide diuretics and calcium-channel blockers are likely to be most
effective in the elderly.
GENERAL MEDICAL SERVICES (GMS) CONTRACT AND
HYPERTENSION
In order to be awarded the maximum number of quality points, practices
must achieve the following standards:
There must be a record of the BP of at least 55% of over-45-year-old
patients within the past 5 years (the under-45s are not mentioned);
this is in order for the practice to be awarded extra organisational
indicator points.
There should be a register in place for patients with established
hypertension.
90% of hypertensive patients should have had their smoking status
recorded at least once and 90% of smokers should have been given
smoking cessation advice.
90% of hypertensive patients should have had a BP recorded within
the past 9 months.
70% of hypertensive patients should have a BP of <150/90 mmHg
(this must be the last recorded reading, which must have been done
within the past 9 months).
At least 55% of diabetic patients should have a BP of <145/85
mmHg (using the last recorded reading).
11 CARDIOVASCULAR DISEASE
ANTIPLATELET THERAPY
ASPIRIN
This should be prescribed at a dose of 75 mg/day for:
Anyone with hypertension over the age of 50 with a CVD risk of
>20% over 10 years
Anyone over 50 with diabetes
Anyone over 50 with target organ damage (eg LVH or renal impairment)
Anyone with established CVD
DIPYRIDAMOLE
The combination of modified-release dipyridamole and aspirin is
recommended by NICE for 2 years after an ischaemic CVA or transient
ischaemic attack (TIA). After this, the patient can revert back to using aspirin
alone. The dose of dipyridamole should usually be titrated up to 200 mg bd
over the course of 2 weeks. Headache is a common side-effect.
Dipyridamole can be used as an alternative to aspirin for patients who are
intolerant of the latter; it should usually be prescribed before clopidogrel in
this case.
CLOPIDOGREL
Clopidogrel should be prescribed in the following circumstances:
For patients requiring anti-platelet treatment who are intolerant of
aspirin and dipyridamole.
In combination with aspirin for up to 12 months following non-ST
segment elevation acute coronary syndrome or unstable angina.
For the first 2 years following an MI of a diagnosis of peripheral
arterial disease in patients who are aspirin intolerant (ie in preference
to dipyridamole.
CHOLESTEROL-LOWERING
Risk charts are designed to allow a CVD risk to be calculated for each
individual patient; this is useful when considering whether to start someone
on BP- or cholesterol-lowering treatment.
12 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
The Joint British Society charts are the ones recommended by BHS and they
have been updated recently to reflect CVD risk rather than CHD risk (see
below), on the basis of evidence from several new trials. They are, however,
still derived from the Framingham data, collected from a cohort of 5000
people from North America who were followed up for 10 years. Diabetes has
now been removed as an extra risk factor, because most diabetics
automatically qualify for treatment with statins. The charts are only intended
to be used for primary prevention. There are just three age bands (<50, 5060
and >60) in the new charts, which means that anyone under 50 will be
considered to be the same age (ie 49) for the purposes of assessing
cardiovascular risk.
Figure 1.3 New Joint British Society CVD risk charts (with copyright permission
from the British Hypertension Society, Joint British Societies CVD Risk Prediction
Chart, Journal of Human Hypertension, 2004, 18, 149150, figure 2)
13 CARDIOVASCULAR DISEASE
Ex-smokers should still be considered to be smokers for at least
5 years after giving up (it is a minimum of 10 years before the risk
comes down to the same level as it is for someone who has never
smoked).
People with a strong family history of premature CVD should
probably have their risk multiplied by 1.5, as should South Asians.
Patients with impaired glucose tolerance, patients with raised
triglycerides and women who have had a premature menopause are
at higher risk than is suggested by the charts.
For hypertensive patients on treatment, pretreatment levels should be
used where possible when assessing risk. Clinical judgement needs
to be used for patients who have been well controlled for years and
for whom a pre-treatment level is not available; however, if using
14 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
treatment BP levels, bear in mind that the patients CVD risk is
probably higher than expected.
Anybody who has a CVD risk of >20% (equivalent to a CHD risk of
15%) for over 10 years should now be considered for statin
treatment according to the BHS guidelines. This has changed from
the previous criterion of CHD risk >30% (equivalent to a CVD risk of
40%); however, from a cost perspective, it is unclear when this could
be realistically implemented nationwide.
Patients with a ratio of total cholesterol:HDL (high-density lipoprotein)
of >7 should usually receive a statin, regardless of other risk factors.
Familial hyperlipidaemia should be excluded (see below).
The new cholesterol targets are: total cholesterol <4.0 mmol/l and
low-density lipoprotein (LDL) cholesterol <2.0 mmol/l, according to
the BHS.
The GMS contract does not specify any lipid targets for people without CVD
or diabetes.
There are some patients in whom the risk charts do not apply the following
groups of patients should be started on lipid-lowering treatment as standard:
Patients with established CVD (including ischaemic stroke, TIA and
peripheral arterial disease).
Patients with type 2 diabetes (particularly if >50 and/or those who
have had the disease for at least 10 years).
Patients >40 with type 1 diabetes (this is a pragmatic approach that
has not been properly validated).
HDL
HDL is cardioprotective, and having a low level (of <1 mmol/l in men and
<1.2 mmol/l in women) is a strong, independent risk factor for CHD. To boost
HDL levels, patients should be encouraged to exercise and to stop smoking.
Drinking moderate amounts of alcohol and eating oily fish at least twice a
week (in particular mackerel, sardines and herring) can also increase HDL.
FAMILIAL HYPERLIPIDAEMIA
The charts do not apply in patients with familial hyperlipidaemia. Familial
hyperlipidaemia should be suspected in patients with a total cholesterol of
>7.5 mmol/l who have a strong family history of CHD. They may or may not
15 CARDIOVASCULAR DISEASE
have physical signs such as corneal arcus or tendon xanthomata (found
commonly on the extensor tendons of the hands, the patellar tendon and the
Achilles tendon). There are many different types of familial hyperlipidaemia,
and often environmental factors such as obesity play as large a part in
subsequent morbidity as do genetic factors. The most common types
encountered in general practice are:
Familial combined hyperlipidaemia (incidence 1:200). The patient
will have raised total cholesterol, LDL and/or triglycerides. HDL is
often low and apoprotein B is elevated. Physical signs are quite rare.
There is a big overlap between this condition and the metabolic
syndrome, with insulin resistance occurring in both. The cause is
poorly understood and diagnosis is difficult. Complicated genetic
factors seem to interact with environmental factors to produce
morbidity. Often, CHD does not occur until a patient is in their 50s
or 60s. Statin treatment is not initially mandatory; see below.
Polygenic hypercholesterolaemia (incidence 1:250). The patient
usually has a cholesterol of >7.5 mmol/l, with raised LDL. They will
probably not have physical signs. Again, environmental factors are
important and statin treatment may not always be necessary.
Familial hypercholesterolaemia (incidence of heterozygotes 1:500,
homozygotes 1:1 000 000). The genetics of this condition are more
straightforward; it is an autosomal dominant condition. Physical signs
are common. Cholesterol is raised from birth and a fatal MI can
occur in the patients 20s or 30s. Statin treatment is essential.
Patients with polygenic hyperlipidaemias may not always need statin
treatment, and can sometimes respond to lifestyle modifications. However, if
they do not, treatment for CVD risk factors should be initiated sooner rather
than later, in order to prevent premature cardiovascular morbidity and
mortality. Diagnosis usually relies on screening the patients family and
genetic testing is rarely helpful.
MONITORING STATINS
There is no need to monitor patients on 10 mg simvastatin.
All other patients should have baseline liver function tests (LFTs),
which should be repeated 13 months after treatment is initiated.
Thereafter, LFTs should be checked at intervals of 6 months for the
first year of treatment, and then annually.
16 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
ANGINA MANAGEMENT
GENERAL MANAGEMENT
All risk factors should be targeted, including lipid levels, smoking, obesity,
inactivity and raised blood pressure. Patients should be screened for diabetes,
and a statin initiated if cholesterol is greater than 3.5 mmol/l and BP reduced
to <130/80 mmHg. Aspirin should be given prophylactically to all angina
sufferers, or dipyridamole if aspirin is not tolerated. Patients should be
investigated for anaemia and thyroid disfunction.
SPECIFIC DRUG TREATMENT OF ANGINA
Sublingual glyceryl trinitrate (GTN) is the best first-line treatment for
an acute angina attack. Patients with normal or low blood pressure
should be warned to sit down before taking it, in case they feel
dizzy.
Beta-blockers are the cornerstone of therapy and should always be
prescribed for angina sufferers unless there is a contraindication; the
dose should be increased to the maximum tolerated. There is definite
evidence of the benefit of long-term beta-blockade post-MI in terms
of morbidity and mortality and, logically, this benefit should also
extend to angina patients. Beta-blockers are also effective in reducing
angina symptoms. (IMAGE study. J Am Coll Cardiol 1996, 27: 3116.)
Beta-blockers should not be stopped suddenly, they should be tailed
off over a period of 4 weeks.
Rate-limiting calcium-channel blockers such as diltiazem and
verapamil are alternative choices for patients intolerant of beta-
blockers. Dihydropyridine calcium-channel blockers (eg amlodipine,
nifedipine and felodipine) are useful when given in combination with
beta-blockers if extra medication is needed to achieve symptom
control. Calcium-channel blockers have not been proved to have a
beneficial effect on mortality, but are useful for preventing angina.
Oral nitrates are effective in preventing symptoms, but the patient
should have at least 12 nitrate-free hours each day to prevent
tolerance. Isosorbide mononitrate (ISMN) can be given in
conjunction with beta-blockers or calcium-channel blockers to
achieve better symptom control.
17 CARDIOVASCULAR DISEASE
Nicorandil is a potassium-channel activator, and is increasingly
being used as the next step after beta-blockers, usually at a dose of
20 mg bd.
The precise role of ACE inhibitors in treating patients with angina is yet to be
clarified. Data from the HOPE study (NEJM 2000; 342: 14553) and EUROPA
study (Lancet 2003; 362: 782) suggest a small additional benefit of ACE inhi-
bition in treating patients with stable coronary artery disease.
GMS CONTRACT AND CHD
In order to be awarded maximum quality points, practices must achieve the
following standards:
There must be a register of patients with CHD.
90% of patients with angina diagnosed after April 2003 should have
had an exercise test or specialist assessment.
90% of CHD patients should have had their smoking status recorded
within the past 15 months (except those who have never smoked, in
which case a single recording is sufficient); 70% of smokers with
CHD should have had smoking cessation advice within the past 15
months.
90% of patients with CHD should have had a BP recording done
within the past 15 months.
At least 70% of CHD patients should have their BP controlled to
<150/90 mmHg.
90% of CHD patients should have had their cholesterol checked in
the past 15 months and this should be <5 mmol/l in 60% of people.
90% of CHD patients should be on aspirin or equivalent.
50% of CHD patients should be on a beta-blocker (unless there is a
specific contraindication).
70% of post-MI patients (diagnosed after April 2003) should be on
an ACE inhibitor.
85% of CHD patients should have a record of influenza
immunisation in the preceding year.
18 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
PERIPHERAL ARTERY DISEASE (PAD)
Again, all risk factors should be targeted, with similar reductions in
cholesterol and BP being aimed for. ACE inhibitors may be beneficial, even
apart from their antihypertensive effect and should be used as first-line agents
in all patients with PAD, regardless of their BP. All patients with PAD should
also be offered a statin.
Diabetes should be excluded; 20% of patients with vascular claudication are
diabetic. Smoking cessation is vital. Aspirin should be prescribed
prophylactically.
The drug cilostazol has been found to increase walking distance in patients
with claudication.
19 CARDIOVASCULAR DISEASE
CVA MANAGEMENT: NATIONAL CLINICAL
GUIDELINES FOR STROKE (JUNE 2004)
Patients who have had a CVA have a 3043% risk of having another stroke
within 5 years. TIA patients have a 20% risk of having a full CVA within the
first month. Aggressive control of risk factors is therefore very important, BP
being the most important one.
All patients with acute CVA should be referred to hospital (patients
treated on a stroke unit have an improved prognosis). In the case of a
TIA, outpatient review should take place within 7 days. However, if
the patient has more than one TIA in the same week, they should be
admitted to hospital. Current stroke guidelines state that CVA patients
should have a brain scan within 24 hours, although this does not
apply to TIA patients.
CVA (with ischaemic aetiology) and TIA patients should receive
300 mg aspirin as soon as possible after their symptoms have
stabilised, and certainly within 48 hours. This is often prescribed in
hospital if the patient is going to be admitted. If not for example in
the case of a TIA it should be prescribed in the community. A
haemorrhagic stroke should be suspected in the following cases:
1 If the patient is on anticoagulants.
2 There is a known bleeding tendency.
3 The patient has a depressed level of consciousness.
4 The patient has unexplained progressive or fluctuating
symptoms.
5 The patient has papilloedema, neck stiffness or fever.
6 The patient describes a severe headache before the onset of
symptoms.
A few centres offer thrombolysis for ischaemic CVA; this must be
given within 6 hours of the onset of symptoms, and only after the
patient has had a CT scan of the brain.
20 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
After the initial dose of 300 mg, aspirin should be continued at a
dose of 75 mg per day, sometimes in combination with modified-
release dipyridamole 200 mg bd for the first 2 years (as per NICE
guidance). Dipyridamole should be started at a low dose and then
increased over 2 weeks, in order to reduce side-effects.
Dipyridamole alone or clopidogrel alone can be used in aspirin-
intolerant patients (according to NICE, dipyridamole should be tried
first).
Lower BP to <140/85 mmHg (or to 130/80 mmHg in diabetic
patients). This should only be done in the acute phase if there are
likely to be complications from hypertension, eg hypertensive
encephalopathy. If not, patients should have their BP monitored, and
hypertension persisting for more than 2 weeks should be treated.
Some centres have stricter BP criteria of 130/80 mmHg for all
patients: in a sense, the lower the BP, the less likely the patient is to
have a recurrence and there is no evidence of a J-shaped curve.
Thiazides and/or ACE inhibitors are usually recommended, even if
the patient is normotensive and, in this case, BP should be reduced
to the lowest level that the patient can tolerate.
All CVA and TIA patients with a cholesterol of >3.5 mmol/l should
be offered a statin unless contraindicated. This is in order to reduce
the risk of a further CVA, but also to reduce the risk of MI; most
patients who have had a CVA have a >30% 10-year risk of CHD.
Check for atrial fibrillation and, if present, consider warfarinisation.
Arrange a carotid ultrasound; endarterectomy is more beneficial if
done within 12 weeks of a TIA. The number of patients you need to
treat in order to save one life is approximately 26. (Cochrane Library
Issue 1, 2004).
Other lifestyle factors are, as usual, very important: smoking (quality
points are given for recording this information and giving smoking
cessation advice), obesity, lack of exercise, salt in the diet (limit to
<6 g/day), etc.
Depression is common in CVA patients; it is always a good idea to
screen for this.
21 CARDIOVASCULAR DISEASE
GMS CONTRACT AND CEREBROVASCULAR DISEASE
In order to be awarded maximum quality points, practices must achieve the
following standards:
There must be a register of all patients with stroke or TIA.
At least 80% of patients who have had a CVA after April 2003
should have been referred for a CT brain scan to confirm the
diagnosis.
90% of patients should have had their smoking status recorded
within the past 15 months (except for people who have never
smoked, when a single recording will suffice) and 70% of smokers
should have been offered smoking cessation advice.
The BP should have been recorded at least once in the past 15
months in 90% of patients.
70% of patients should have a BP of <150/90 mmHg.
90% of patients should have had their cholesterol checked in the
past 15 months and this should be <5 mmol/l in 60% of people.
90% of patients with non-haemorrhagic CVA should be on aspirin or
an equivalent.
85% of patients should have a record of influenza immunisation in
the preceding year.
22 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
HEART FAILURE
The median age at diagnosis is 76. The incidence overall is approximately
0.9/1000 per year, but is much higher in the over-85 age group (approaching
1% per annum). NICE updated their guidance in 2003 and the following
section is based on these guidelines.
DIAGNOSIS
A diagnosis can be made on the basis of ECG and B-type natriuretic peptide
(BNP) tests. BNP is a highly sensitive test, and if it is negative the patient can
be reassured that they do not have heart failure (Table 1.2). It is not
particularly specific however, so people who test positive do not necessarily
have left ventricular dysfunction (LVD), but should be referred for
echocardiography to confirm the diagnosis.
BNP measurement is not available to all GPs; in this case, referral for echo
should be based on ECG findings. Patients with LVD will usually have ECG
abnormalities, eg left ventricular hypertrophy. Patients who have a normal
echo, but clinically still have symptoms of heart failure, may have diastolic
dysfunction. They should be referred to a specialist for diagnosis.
Other recommended investigations are: chest X-ray (CXR), spirometry (to
exclude a respiratory problem) and baseline blood tests (full blood count
(FBC), U&Es, lipids, glucose, thyroid function tests (TFTs)).
BNP value (ng/l) Interpretation
<50 in young people or <100 in the elderly Heart failure excluded
100600 Borderline
>600 Heart failure very
likely
Table 1.2: Interpretation of the BNP test
TREATMENT
Lifestyle measures are vital: smoking cessation, a low-salt and low-fat diet,
alcohol reduction and exercise training. Alcohol-induced cardiac failure is
more common than most people realise, and patients should always be asked
23 CARDIOVASCULAR DISEASE
about their intake. Medication should be reviewed and stopped if it is likely
to be making the LVD worse (eg non-steroidal anti-inflammatory drugs
(NSAIDs), lithium, steroids). If the patient cannot do without an NSAID, it is
better that they are on a low dose of ibuprofen than other, more cardiotoxic,
drugs such as diclofenac or indometacin. Valvular heart disease (eg aortic
stenosis) can result in cardiac failure and is potentially reversible. Drug
treatment improves morbidity and mortality in LVD and should be initiated as
follows:
Aspirin (75 mg/day).
ACE inhibitors and ARBs: these should be started off at a low dose
and titrated upwards. U&Es need to be checked about 1 week after
treatment is started. ACE inhibitors are usually used as first-line
treatment, and an ARB is substituted if the patient is intolerant; the
CHARM alternative (Lancet 2003; 362: 759781) and VALIANT (New
England Journal of Medicine 2003; 349: 20) trials have shown that
ARBs are also effective in heart failure. The ACE inhibitor dose
should be doubled at intervals of at least 2 weeks, aiming for the
target dose for LVD (eg lisinopril 30 mg od, ramipril 10 mg od or
enalapril 20 mg bd). Rises in creatinine of 50% from the baseline
value or up to 200 mmol/l (whichever is smaller) are acceptable.
There is a huge amount of trial data supporting the use of ACE
inhibitors in heart failure (eg Consensus, NEJM 1987; 316: 142935
and Solvd NEJM 1991; 325: 293302)
Beta-blockers: only the selective beta-blockers, bisoprolol,
metoprolol and carvedilol have been used in the big heart failure
trials (CIBIS II, Lancet, 1999; 353: 913 and MERIT-HF, Lancet
1999; 353: 20017, and Copernicus, NEJM 2001; 344: 16518 and
BEST, NEJM 2001; 344: 165967) and it is one of these three which
will normally be initiated for heart failure. However, if a patient is
already on a non-selective beta-blocker prior to their diagnosis, they
can continue on it. Beta-blockers should be introduced very
cautiously, starting off with a low dose (1.25 mg od for bisoprolol
and 3.125 mg bd for carvedilol) and titrating upwards over several
weeks; the dose should be doubled at intervals of no less than 2
weeks, until target therapeutic doses are reached, and the patient
should be warned that they might initially feel worse. Beta-blockers
should only be introduced once the patient is stabilised on their final
dosage of ACE inhibitor. Only patients with stable heart failure
should be tried on beta-blockers; these drugs should never be
introduced in patients with worsening symptoms.
24 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE
Diuretics produce significant functional improvement. Impact on
mortality and general prognosis is not known. They should be used
as a matter of course, to help with symptoms of breathlessness.
Diuretics are less helpful in patients with diastolic dysfunction.
Spironolactone may decrease mortality if used in addition to the
above treatments, at a dose of 25 mg od (RALES trial, Lancet, 1999;
341: 70917). Hyperkalaemia and renal impairment are possible,
and potassium levels should be carefully monitored.
Digoxin can be started in any patients with LVD and concomitant
atrial fibrillation. It can also be used in patients in sinus rhythm as an
adjunct to ACE inhibitors, diuretics and beta-blockers if necessary.
DIASTOLIC DYSFUNCTION
Patients with a normal ejection fraction on echo may still have diastolic
dysfunction; this should be suspected if the history is suggestive of heart
failure and other diagnoses such as COPD and dyspnoea due to obesity have
been excluded. These patients are often hypertensive, but may not complain
of very much peripheral oedema. In general, diastolic dysfunction is a less
serious disease than LVD and is less likely to result in admission. Patients
should be treated in a similar way, but rarely benefit much from diuretics
because they are not usually oedematous.
GMS CONTRACT AND LVD
Maximum quality points are awarded to practices who achieve the following
standards:
A register of patients with CHD and LVD.
Echocardiographical confirmation in 90% of their LVD cases
diagnosed after April 2003 (in patients with concomitant CHD only).
At least 70% of patients with LVD and CHD should be prescribed
ACE inhibitors or ARBs.
25 CARDIOVASCULAR DISEASE
ATRIAL FIBRILLATION
Rate control is at least as important as rhythm control in atrial fibrillation
(Affirm study. New England Journal of Medicine 2002; 347: 1825), so a
medication such as a beta-blocker, a rate-limiting calcium-channel blocker or
digoxin that slows the pulse rate should be considered. Untreated atrial
fibrillation is a strong risk factor for CVA, with an incidence of approximately
5% per year overall.
Patients with the following risk factors are at moderate or high risk of having
an adverse outcome from untreated atrial fibrillation and should be
considered for anticoagulation with warfarin:
Previous history of CVA or TIA (very high risk should definitely
receive warfarin).
Hypertension, LVF or diabetes (high risk if >65 should definitely
receive warfarin; moderate risk if <65 consider warfarin).
>65 years of age with no other risk factor (moderate risk consider
warfarin).
If high-risk patients are deemed unsuitable for warfarinisation, they should
receive high-dose aspirin 300 mg od(/).
Patients who are over 65 without additional risk factors and those under 65
with co-existent diabetes, CHD or hypertension should be offered a choice
between warfarin and aspirin. Patients under 65 with no additional risk
factors should be given aspirin at a dose of 75150 mg per day.
26 GENERAL PRACTICE THE CLINICAL SURVIVAL GUIDE